CLM-2026-032949
Evergreen Counseling Center, Behavioral Health. Service 2026-09-01 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Eugene Edwards
- Member ID
- UHC-48436-70
- Date of birth
- 1968-07-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430906
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6560
- Coverage period
- 2023-03-01 to 2026-07-26
- Deductible
- $467.81 of $1,500.0031%
- Out-of-pocket maximum
- $1,506.85 of $6,000.0025%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 3227561461
- Location
- Los Angeles, CA · TIN 43-3815206
- Authorisation / referral
- none / REF671957
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $220.00 | $136.40 | — | — | DeniedCO27 |
| Totals | $220.00 | $136.40 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-978655
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036828 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-01 is after coverage terminated on 2026-07-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Counseling Center (9886050688). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Counseling Center2026-09-01 13:44
Patient seen for post-traumatic stress disorder, unspecified.
- SystemSystem: Claims system2026-09-24 00:27
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-24 15:29
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-01 is after coverage terminated on 2026-07-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019811 | 2026-06-19 | Pinecrest Family Practice | $238.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.